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Rhabdomyolysis with Dr. Howard Elkin & Dr. Ben Weitz: Rational Wellness Podcast 344

Dr. Howard Elkin and Dr. Ben Weitz discuss Rhabdomyolysis.

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Podcast Highlights

2:17  Rhabdomyolysis (rhabdo) is characterized by an acute destruction of muscle tissue and the contents of the destroyed muscle tissue–myoglobin–is emptied into the bloodstream.  This myoglobin makes the urine appear brown in color and thick and it can overwhelm the kidneys and cause kidney destruction and renal failure.  75% of the time such patients are men over the age of 30 and dehydration and certain medications can increase the incidence.  From 2005 to 2015 there has been a 12 fold increase in rhabdomyolysis in the US and this is largely related to the trend towards high intensity workouts at bootcamps and Crossfit and other High Intensity Training gyms like Orange Theory that often attract people who have not been exercising and some of whom end up overdoing it in such class type situations. 

6:24  Certain drugs like statins that are used to lower cholesterol can play a role in causing rhabdo, since they can adversely affect skeletal muscles, though this is more common in the older statins that are lipophilic like simvastatin (Zocor) and atorvastatin (Lipitor) than the newer statins that are hydrophilic like fluvastatin, rosuvastatin (Crestor), and pravastatin.  This can be made worse if certain other drugs are taken at the same time that inhibit the cytochrome p450-3A4 liver detox pathway, such as certain antibiotics (such as clarithromycin), antifungals, calcium channel blockers and certain other drugs.  Also, the use of alcohol, amphetamines, and methamphetamines can worsen the likelihood of the occurrence of rhabdo. 

8:34  Patients with rhabdo usually present with intense pain, extreme fatigue, and their urine is very dark, even brown, because of myoglobin that is being released.  They will have elevated CPK in their blood as well as elevated myoglobin.  It should also be pointed out that bodybuilders may have modest elevations of their CPK due to weight training and breaking down muscle tissue. Normal CPK is between 20 and 120 and bodybuilders may have CPK up to 500, while some rhabdo patients may present with a CPK of 10,000 or 100,000 or even higher. 

12:09  While anabolic steroids can be damaging to health and are likely responsible for the deaths of quite a number of bodybuilders, they are not likely contributing to rhabdo despite claims made in some of the scientific papers published about rhabdo.  Rhabdo involves a state of extreme breakdown of muscle or catabolism, while anabolic steroid are anabolic and they promote muscle recovery and muscle building.  On the other hand, many patients take corticosteroids for inflammation, extreme infections, asthma, etc. and these are catabolic and could contribute to rhabdo. 

14:47  Steps to avoid rhabdo include all the things you would do to avoid overtraining.

           

 

Dr. Weitz:            Right. Now, what are some of the steps that bodybuilders and fitness enthusiasts can do to avoid rhabdo? Well, since this is a form of extreme over-training, we need to do all the things you would do to avoid over-training. So that means if you’re just starting to engage in a new form of exercise, maybe you were a runner, now you’re going into weight training, or vice versa, if you’re just starting a CrossFit program, maybe you haven’t been exercising very much, or maybe you took a break from exercising, you need to gradually ramp up your intensity, your duration, and the frequency of your exercise. In other words, let’s say you took six months off from training and now you’re going to start training for an hour a day in a high intensity class, five, six days a week, you’re probably asking for trouble. So start out every few days, slowly increase your intensity.

                                Now, that’s one of the problems with some of these classes is you can’t start off at your own pace. So you’re probably better off starting out in a gym by yourself slowly increasing the duration and intensity of your exercise. You jump into a class an hour class, everybody’s at a high level already, that’s one of the problems that can happen. Also, avoiding exercise in extreme heat. So don’t run a marathon in the summer in Arizona. High heat conditions, not being properly hydrated, not having a proper balance of electrolytes is another thing that can increase your potential for having rhabdomyolysis. It’s also important that you make sure that you’re sufficiently recovered from your workouts. So you’re into a new workout program and you feel like you can handle it because you’ve been working out and now maybe you’re on day three, four or five and you can barely get out of bed.

                                Your body’s telling you you probably are starting to be overtrained, and that’s something you want to avoid. There’s also something called heart rate variability, which we want to discuss in another talk, but that’s a sign when your heart rate variability decreases that you’re overtraining. Also, when you’re working out, you need to make sure that you’re consuming sufficient amounts of protein, carbohydrates, and calories to help you recover from your workouts as well as getting good quality sleep. So if you’re in a situation where you’re traveling where you haven’t been able to sleep, you’re suffering work or relationship stress, or maybe you’re doing extreme dieting like a competition bodybuilder, getting ready for a competition, and let’s say in addition to working out six days a week with heavy weights, now you’re doing large amounts of cardio. Maybe you’re doing an hour or two hours of cardio a day, you’re also practicing your posing and you’re doing an extreme diet.

                                That’s something you’ve got to be careful about. That might put you in a situation where you could end up with rhabdo, especially if you’re also taking stimulants. And we know that people exercise sometimes take stimulants before they work out, like with pre-workout drinks or they have these energy drinks. Those can have large amounts of caffeine and they can have multiple forms of stimulants, so they could have caffeine. They could also have other herbal stimulants that combined with caffeine could end up being a large amount of stimulant.

                                I think having a cup of coffee or a cup of green tea or something like that is probably fine, but I would recommend for the most part, avoiding most of these energy drinks that are out there. And of course, people who are going for competition, like some of these bodybuilders and fitness people, they sometimes take stimulants to help them reduce their body fat, to reduce their appetite. So the one popular stimulant is called clenbuterol, which is sort of an asthma medication, but it also reduces appetite and is used by fitness and bodybuilding people to help get lean for bodybuilding shows. And that’s something that puts you at risk.



Dr. Howard Elkin is an Integrative Cardiologist with offices in Whittier and in Santa Monica, California and he has been in practice since 1986.  While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for diet, lifestyle changes, and targeted nutritional supplements to improve their condition.  Dr. Elkin has written an excellent new book, From Both Sides of the Table: When Doctor Becomes Patient.  His website is Heartwise.com and his office number is 562-945-3753.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations and he uses DUTCH testing regularly.

 



 

Podcast Transcript

Dr. Weitz:            Hello, Rational Wellness podcasters. I’m here today with my friend, integrative cardiologist, Dr. Howard Elkin, and our goal is to comment on a potentially very serious condition, rhabdomyolysis, that’s been in the bodybuilding news recently. We will explain what this condition is, what causes it. We will try to clarify what types of drugs may play a role in it and what we can do to avoid it. To make our lives easier today, we will refer to rhabdomyolysis henceforth in this discussion as rhabdo. While rhabdo is not super common, there are 26,000 reported cases per year in the US and this can be a potentially life-threatening condition. There’ve been a number of commentators on YouTube recently discussing rhabdo who are not medical professionals, including some popular YouTubers in the bodybuilding world who generally do an excellent job providing accurate information, but they may not have provided the most accurate advice about this condition.   We thought it was important for two doctors who have both competed as bodybuilders to weigh into this discussion to provide a more nuanced discussion of rhabdo. Our goals are to help you understand what is rhabdo, what causes it, and how to prevent it. We also wanted to clarify which medications might play a role and which medications likely do not, despite what some commentators have claimed. And you can expect Dr. Elkin and I to be commenting about a number of other topics in the fitness and bodybuilding world in the coming months. Dr. Howard Elkin is an integrative cardiologist, and myself, Dr. Ben Weitz, I’m a sports chiropractor and functional medicine practitioner. We both have been practicing doctors for decades and we both have experience competing in bodybuilding in our past. So we feel that we can bring both medical understanding and bodybuilding insights to contribute to this type of discussion. So welcome Dr. Elkin, and why don’t you start us off by explaining what is rhabdo, how is it diagnosed, what causes it?

Dr. Elkin:              Hey, good morning Ben. Thank you so much for inviting me. This is a topic that’s dear to me. So rhabdo, I believe it means to break down or break up, and myolysis is muscle tissue. So this really, this condition is characterized by an acute destruction of muscle tissue and what happens, the contents of the destroyed muscle tissue is actually emptied into the bloodstream. So you’ve got muscle fiber contents like certain metabolites like potassium, phosphorus, and urea, but more important, you have a release of the actual contents of the muscle itself called myoglobin, and along with something called CPK or creatinine, creatine phosphokinase. So it’s the myoglobin that does the damage. And once this is released into the bloodstream, it goes to the kidney and it overwhelms the kidney. It actually can destruct some of the kidney tubules. So the major issue or morbidity or mortality is acute renal failure, which is not insignificant.

                                I think what I’ve read anywhere from 10 to like 40%, that’s a pretty big, it’s huge. So it can potentially very serious situation. Now, like Ben says over, it’s not common, but it certainly isn’t rare. Over 20,000 people in this country have developed rhabdomyolysis yearly, but this is important. This has been a 12 fold increase rhabdomyolysis from 2005, 2015, which is pretty huge, and we think, from what I can gather, it’s the high intensity workouts that people were now doing. The bootcamps and the CrossFit and the Orange Theory and what happens, these are basically group classes and they attract people that are fitness enthusiasts that a lot of them are novices. They don’t really have the background, they haven’t really trained their muscles, so they’re getting into a pretty intense program in a very short period of time. Now, I would like to read how things developed.

                                So we didn’t really know much about this until the ’40s. It was really described as a crush syndrome because it was observed in British people during the blitz in the ’40s in World War II. And what happened, there were crush injuries and people were brought to the hospital and whatever they did back then, they didn’t do a lot. They didn’t have dialysis, but then they would go home and they would die a few days later of renal failure. They didn’t have dialysis back then, so it was kind of called the crush syndrome until they changed the name to rhabdomyolysis. Now, this is very important. About 47% of patients that develop this are engaged in vigorous exercise. So it’s more seen, but you can see it in lots of different situations as well, which I’ll mention. But again, it’s almost half of the people that developed the syndrome or engaged in various exercise.

                                Now, and here’s another thing, 75% are males, 75%, and generally less than the age of 40. So that tells you something. Men tend to be more, I guess they engage in more hazardous activities. And this [inaudible 00:05:46] that I also read. 30% develop on the same day of the exercise, but 55% within 48 hours. So it’s acute and subacute. It can happen immediately or it can happen up to 48 hours afterwards. It’s really not commonly seen in elite athletes because their muscles are more refined, or in the totally untrained muscles because they can’t handle the workout. But it’s this big gap in between and these fitness enthusiasts that are engaged in these activities. So it’s usually male non-elite regular exercisers over the age of 30, and it increases the incident, increases in the situations of dehydration, certain drugs that we’ll talk about in a second.

                                And I’m a cardiologist, so I use statins a lot in my practice, especially in those that have a history of heart disease. But statins are metabolized by a certain process in the liver called the cytochrome P450 system. And certain drugs like this and certain antifungal medications and certain anti-psychotic medications can actually, they’re metabolized by the liver in this particular system, and this can make it more prone to develop this syndrome. I don’t see it as much in my practice now because this is the old generation of statins that like the lovastatin, which is the first one that came out in the mid-80s, actually about ’84, ’85, I was a fellow. And then Simvastatin, which is commonly known as Zocor, but I mentioned Zocor specifically because that was one that is metabolized by the cytochrome P450 system, and that was the statin of choice before Lipitor came out in the late ’90s. And all these studies on secondary prevention and the use of statins with the use of Zocor. So you still see some people on it, I haven’t prescribed it in years.

Dr. Weitz:            So essentially these older statins are fat soluble versus the newer water-soluble statins.

Dr. Elkin:             Correct.  Right.  So the most protective ones would be Pravastatin, which actually was used early on.  It was never really, it didn’t achieve a lot of popularity because it wasn’t nearly as effective as some of the other ones.  But Rosuvastatin, commonly known as Crestor, is a water soluble statin that I personally use for my patients, and it’s relatively safe, but it’s good to know these things.  And also the worst offenders are things like alcohol use, which is very dehydrating, and amphetamine and methamphetamine use, which is very dehydrating, also stimulates the heart. So there’s a myriad of situations that can make this whole situation worse.

Dr. Weitz:            By the way, Howard, when somebody presents with rhabdo, what are the presenting symptoms? What does this picture look like?

Dr. Elkin:              Okay, usually we’re talking, this is not a little bit of muscle soreness that you get from exercising, which is a different situation. Usually it’s intense pain, intense pain in the area that’s involved swelling, but it’s pain, fatigue, extreme fatigue. And also the urine turns very dark because of the myoglobin. And so we’re talking like dark, like brown or very dark yellow. It is not normal urine. So that’s how they present. They have symptoms, it’s not asymptomatic. They have urine that is discolored. And also there’s a test you can do, CPK, which stands for creatinine phosphokinase, is an enzyme in muscle that’s released during heavy vigorous muscle muscular activity and also with rhabdo, but it’s not the thing you want to look for.  Because bodybuilders, I mean, I’ve had an elevation in CPK before, so it can last a couple of days or so after vigorous workout. So that is a muscle enzyme that isn’t the one we’re really concerned with. What you want to measure is myoglobin. Myoglobin is actually the protein that makes muscles work, and that’s released with this acute destruction of the muscle fibers, and that’s what you pick up and not just in the blood, but also in the urine. So it’s microalbuminuria and myoglobinuria. Those are the two main lab tests. So it’s really-

Dr. Weitz:            The other thing I’d like to point out on the CPK is while bodybuilders, so let’s say a normal CPK, depending upon the lab, the range might be between 20 or 40 and 120 or 150 or somewhere in that range, maybe up to 200, bodybuilders who are working out really intensely who are breaking down a lot of muscle tissue might see, especially after a workout or for a period after the workout, might see an elevation of their CPK up to 500, maybe even up to 1,000. But some of these patients with rhabdo present with CPK levels of 10,000, 100,000, and even higher. At that point, we know we’re dealing with rhabdo, and it’s not just a result of working out,

Dr. Elkin:              Right. That’s very important distinction. I mean, you can look at it like this. When we exercise intensely, you may get some muscle soreness a day or two later that’s called DOMS delayed onset muscle soreness. Now, some people say that could be a very mild case of rhabdo, and it’s important to bring this out because how you grow in both its strength and muscle mass is you break the muscle down when you exercise, then it has to rebuild. So there is a little bit of muscle destruction that takes place with a vigorous workout, but not to the extent that we’re talking about.

Dr. Weitz:            Yeah, you’re basically talking about some level of maybe over-training. And that’s something we want to comment about in a future talk is describe exactly what over-training is, how you can monitor it with heart rate variability, et cetera.  But this is a really extreme form of over-training, an acute situation.

Dr. Elkin:              Right. So let me ask you now, Ben, now that we know what this syndrome is and how it’s diagnosed, how do we prevent it?

Dr. Weitz:            Okay, well, first of all, I want to make a comment about one of the types of drugs that is often attributed as being a cause of rhabdo. And I’ve seen a number of reports, scientific reports in the literature where the doctor who writes a report blames anabolic steroids on being the cause of rhabdo. And while I don’t defend anabolic steroids, and we have certainly seen our share of anabolic steroid health problems and death among bodybuilders, and of course, you and I previously commented in a YouTube video that we call dead bodybuilders about all the bodybuilders who’ve suffered cardiovascular and renal and liver problems from anabolic steroids.  This is one case where I don’t think that anabolic steroids properly play a role. Because in rhabdo, you’re getting an extreme breakdown of muscle tissue and anabolic steroids are anabolic, not catabolic. They’re building up muscle, they’re helping recovery, not breaking it down. On the other hand, if the person is taking a steroid known as a corticosteroid, like prednisone, for a number of conditions, including inflammation or extreme infections, et cetera, certain autoimmune diseases, that could contribute to rhabdo, but we don’t think that anabolic steroids can.

Dr. Elkin:              So remember, anabolic means to build, catabolic means to break down, and a lot of people take corticosteroids. They’re used all the time and they have distinct benefits, but they have some major drawbacks, and this is one of them. But I think you’re right, steroids have been blamed for everything. Okay, you name it, and oftentimes unfairly so. But again, we’re not condoning the use of steroids, but we don’t want you to walk by saying, “Oh, this is another thing with steroids.” It’s not true. Again, most of these exercisers weren’t professional bodybuilders. We know of one that is, but it’s these vigorous, so in other words, it’s not elite athletes or elite bodybuilders, but that’s an important distinction. So let’s not blame this particular syndrome on steroid use.

Dr. Weitz:            Right. Now, what are some of the steps that bodybuilders and fitness enthusiasts can do to avoid rhabdo? Well, since this is a form of extreme over-training, we need to do all the things you would do to avoid over-training. So that means if you’re just starting to engage in a new form of exercise, maybe you were a runner, now you’re going into weight training, or vice versa, if you’re just starting a CrossFit program, maybe you haven’t been exercising very much, or maybe you took a break from exercising, you need to gradually ramp up your intensity, your duration, and the frequency of your exercise. In other words, let’s say you took six months off from training and now you’re going to start training for an hour a day in a high intensity class, five, six days a week, you’re probably asking for trouble. So start out every few days, slowly increase your intensity.

                                Now, that’s one of the problems with some of these classes is you can’t start off at your own pace. So you’re probably better off starting out in a gym by yourself slowly increasing the duration and intensity of your exercise. You jump into a class an hour class, everybody’s at a high level already, that’s one of the problems that can happen. Also, avoiding exercise in extreme heat. So don’t run a marathon in the summer in Arizona. High heat conditions, not being properly hydrated, not having a proper balance of electrolytes is another thing that can increase your potential for having rhabdomyolysis. It’s also important that you make sure that you’re sufficiently recovered from your workouts. So you’re into a new workout program and you feel like you can handle it because you’ve been working out and now maybe you’re on day three, four or five and you can barely get out of bed.

                                Your body’s telling you you probably are starting to be overtrained, and that’s something you want to avoid. There’s also something called heart rate variability, which we want to discuss in another talk, but that’s a sign when your heart rate variability decreases that you’re overtraining. Also, when you’re working out, you need to make sure that you’re consuming sufficient amounts of protein, carbohydrates, and calories to help you recover from your workouts as well as getting good quality sleep. So if you’re in a situation where you’re traveling where you haven’t been able to sleep, you’re suffering work or relationship stress, or maybe you’re doing extreme dieting like a competition bodybuilder, getting ready for a competition, and let’s say in addition to working out six days a week with heavy weights, now you’re doing large amounts of cardio. Maybe you’re doing an hour or two hours of cardio a day, you’re also practicing your posing and you’re doing an extreme diet.

                                That’s something you’ve got to be careful about. That might put you in a situation where you could end up with rhabdo, especially if you’re also taking stimulants. And we know that people exercise sometimes take stimulants before they work out, like with pre-workout drinks or they have these energy drinks. Those can have large amounts of caffeine and they can have multiple forms of stimulants, so they could have caffeine. They could also have other herbal stimulants that combined with caffeine could end up being a large amount of stimulant.

                                I think having a cup of coffee or a cup of green tea or something like that is probably fine, but I would recommend for the most part, avoiding most of these energy drinks that are out there. And of course, people who are going for competition, like some of these bodybuilders and fitness people, they sometimes take stimulants to help them reduce their body fat, to reduce their appetite. So the one popular stimulant is called clenbuterol, which is sort of an asthma medication, but it also reduces appetite and is used by fitness and bodybuilding people to help get lean for bodybuilding shows. And that’s something that puts you at risk.

Dr. Elkin:              And one other thing, Ben, that’s very important, ibuprofen or NSAIDs, nonsteroidal anti-inflammatory agents, commonly used by bodybuilders and not just bodybuilders, people in general. I’m very bullish on trying to avoid this stuff and myself and my patients. Acutely, it’s fine to take, but on a regular basis, and there’ve been many bodybuilders who have developed renal failure as well, taking. And there’s actually a case report that I read in 2023, yeah, last year of a young bodybuilder who was taking ibuprofen ended up in the merchant room with rhabdomyolysis. So that’s another thing to be on the watch for.

Dr. Weitz:            Absolutely. I know my share of professional athletes who ended up needing kidney transplant due to taking nonsteroidal anti-inflammatories. Interestingly, there was a period of time that nonsteroidal anti-inflammatories like ibuprofen were actually recommended to reduce your post-workout soreness. They actually claimed that they would help you recover. So it was really common at one point for a lot of athletes to automatically take nonsteroidal anti-inflammatories after their workouts thinking that it was actually beneficial. And in fact, you’re putting yourself at risk. Another thing that bodybuilders and fitness people do sometimes to help lean out is to take thyroid. Now, if you’re hypothyroid, you have a medical condition, your thyroid’s not producing enough thyroid, there is certainly a good reason to take thyroid medication, and there’s a safe way to do it, knowing what your levels are, taking appropriate levels, monitoring it. However, a lot of bodybuilders and fitness people take thyroid even though they don’t need thyroid just because they’re trying to increase and put themselves in a hyper thyroid state so that they’ll burn more fat. In fact, they may end up burning more muscle and put themselves more at risk for rhabdo.

Dr. Elkin:              I think we covered it.

Dr. Weitz:            So I think the message to get from this for the average person is if you’re going to be exercising intensely, and we recommend that everybody do exercise intensely, that you slowly ramp up to it, slowly increase your intensity, your frequency, and your duration of exercise, make sure you’re fully recovering. So get your exercise in, but do it safely. So now that we’re wrapping up, Howard, why don’t you tell our viewers how they can get in touch with you?

Dr. Elkin:              Okay, great. You can get in touch with me by two websites. One is heartwise.com, and the other one is beyourownmedicaladvocate.com, which is actually for my book that I put out a year ago. And on Instagram, it’s D-O-C-H Elkin, Doc H Elkin, and on Facebook, it’s HeartWise Fitness and Longevity Institute. So please feel free to contact me and follow me on social media.

Dr. Weitz:            That’s great. And I’m Dr. Ben Weitz. You can contact me through my website, D-R-W-E-I-T z.com. If you want to do a functional medicine consultation, you can call my office at 301-395-3111, you can also follow me on social media on Instagram @drbenweitz, and follow this podcast, the Rational Wellness Podcast. You can watch it on YouTube, you can listen to it on Spotify and Apple Podcasts. And if you enjoy it, please give us a five star rating and review, and we will see you next time.

 

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